Stroke of luck

Suzy Morgan had a stroke on March 1, 2010. Three weeks later, she was back at work.

Suzy Morgan

Many things undoubtedly contributed to her amazing recovery, but perhaps the most important was speed: Her husband immediately recognized her symptoms and called 9-1-1. His suspicion was quickly confirmed in the Emergency department at Community Hospital. A clot-busting drug — most effective when given within 41/2 hours of a stroke — was administered in time.

Delay in the process might have meant a radically different outcome for Morgan. Strokes kill about 144,000 people each year in the United States; many who survive have serious long-term disabilities. Morgan’s experience left her shaken, but the only physical reminder is a little unsteadiness in her handwriting.

“I work with stroke patients,” says Morgan, a nurse at Community Hospital. “I’ve definitely seen what can happen with a stroke. The big picture is I could be in a rehabilitation center and not able to walk or talk. So if my writing is a little shaky, I’ll take it.

“When the stroke was happening, the doctor asked me if I’d had any trauma. I hadn’t. He said it was just a spontaneous thing that happens. I said, ‘Lucky me; I would rather have won the lotto.’ He said, ‘You did.’ And he’s right.”

The goal at Community Hospital is to have as many of those lotto-winning-like outcomes as possible. To increase the odds, the hospital undertook a rigorous effort to become a certified primary stroke center, a designation that recognizes its ability to improve outcomes for people who have strokes. The certification is awarded by the Joint Commission, the nation’s leading healthcare accreditation organization, based on examination of months of patient information and an on-site review. Community Hospital won the designation nearly two years ago, making it a critical resource in Monterey County, where an average of two people a day have a stroke.

“The designation means that we are trained to provide consistent stroke care based on demonstrated best practices,” says Laura Hodge, RN, stroke program coordinator. “There are a series of protocols we go through for stroke and potential stroke patients, and everyone involved knows them and follows them so that we can have the best results possible.”

When patients like Morgan arrive at Community Hospital, a two-word call to action goes out over the paging system: Code Stroke. That sets in motion a chain of events designed to stop a stroke or minimize its impact.

“Every stroke patient is considered an emergency,” Hodge says. “The saying is ‘Time is brain,’ meaning the more time that elapses, the greater the chance of lost brain function.”

The page alerts a stroke team consisting of Emergency department staff, a neurologist, and staff from Radiology, Pharmacy, and Laboratory Services, all trained to work together to prepare for immediate diagnosis and treatment.

An Emergency department doctor is ready to evaluate the patient within the first 10 minutes of his or her arrival.

A radiologic technologist readies a CT scanner to capture images of the patient’s brain and carotid arteries within 25 minutes of arrival.

A radiologist is on standby to read the scan results within 45 minutes of arrival.

Since mid-2009, more than 660 stroke patients have been treated at Community Hospital, and the Code Stroke team has been activated more than 300 times to treat those who arrived at the Emergency department soon after the onset of stroke symptoms.

In nearly 50 cases, patients received tPA. As long as the cause of stroke is an arterial blockage, tPA, when administered during its window of opportunity, can dissolve the clot before it causes the blood vessel to burst. That can enable stroke symptoms to subside before permanent damage occurs.

“By administering tPA, we have experienced a high percentage of positive outcomes,” Hodge says. “That’s why it’s so important for the community to act fast. If you think you might be having a stroke, get to the Emergency department as soon as possible to receive any and all treatment while there is time to make a difference.”

Without tPA to break down the clot, it can progress to the point where the patient is robbed of the simplest cognitive and physical skills that control the daily activities of life.

If the blood clot has time to grow, the integrity of the vessel can be compromised, causing a weakness in the blood vessel. This area forms a balloon that can burst, resulting in a hemorrhagic stroke. The surrounding brain tissue, affected by the bleeding, loses oxygen, and corresponding body functions cease. Depending on how long the brain goes without oxygen, that tissue can die.

“When I talk with patients,” says Hodge, “many don’t truly understand what stroke is, that it occurs in the brain and not the heart, and that it is extremely serious. If the stroke does involve bleeding in the brain, it can be devastating and kill quickly. If given the chance to administer treatment, we may be able to slow or stop the bleeding.”

The clot-busting drug doesn’t always work, but research and experience demonstrate that it works often enough to make it worth the effort to get to the hospital in time to try. Sometimes the clot is too big and the preferred approach is to remove it through surgical intervention. In either case, experts say, patients are better off being taken to a hospital practiced at treating strokes so that knowledgeable decisions can be made as quickly as possible in an effort to minimize damage.

After a stroke, patients are usually in the hospital for three to five days. Those who received tPA will be moved to the Intensive Care Unit (ICU) for close monitoring; others may go to the ICU or to a regular nursing unit. From there, some are discharged home, while others may need to be moved to a skilled nursing facility for care and rehabilitation.

“Nearly everyone is more afraid of being disabled than dying,” says Anwar Duensing, RN, a member of the stroke team. “Our Code Stroke system is an effort to prevent or minimize disability.” Staff members get continuing education to stay abreast of the latest in stroke treatment and care. A stroke work group meets regularly to review the latest evidence-based research and to consider and carry out any appropriate changes in protocols.

“Our goals are keeping up with the newest treatment and educating the public to recognize symptoms,” Duensing says.

Those symptoms are spelled out under the acronym FAST, which stands for face, arms, speech, and time. If you think someone has had a stroke, act FAST:

Face: Ask the person to smile. Does his or her face droop?

Arms: Ask the person to raise both arms. Does one drift downward?

Speech: Ask the person to repeat a simple phrase. Is speech slurred or strange?

Time: If you observe any of these symptoms, call 9-1-1 immediately.

While fast action is the best response to a stroke, prevention is even more important.

“Stroke prevention,” says Hodge, “involves managing risk factors such as high blood pressure or cholesterol, obesity, smoking, stress, and the incidence of a transient ischemic attack (TIA) or ‘mini stroke.’ After a TIA, blood flow is often naturally restored and symptoms usually resolve within 24 hours. Yet, since 90 percent of patients who experience a TIA will go on to have a full stroke, we don’t take TIAs lightly. This is your red flag and our opportunity to evaluate risk factors and determine how to minimize or control them.”

Suzy Morgan didn’t fit the profile. She was only 44 when her stroke occurred. As a registered nurse, she is fully aware of the benefits of a healthy lifestyle. She jogs, goes to a gym, and watches her cholesterol. Her stroke occurred because a tear developed in her carotid artery.

“It was kind of a fluke; the chance of it happening was one-in-a-million,” she says.

After her emergency treatment at Community Hospital, Morgan was transferred to Good Samaritan Hospital in San Jose, a certified stroke center with which Community Hospital works on certain types of stroke cases. There, Morgan had a stent placed in her damaged artery. After about a week, she was home. In two more weeks, she was back at work.

“It’s been a rocky year,” she says. “I was kind of surprised at the emotional impact the stroke had on me. But I have an incredible family, incredible friends, and all my work buddies have been amazing to me. And I am certainly lucky. Everything about my care was textbook.”

What is a stroke?

A stroke, or brain attack, occurs when a blood clot blocks an artery (a blood vessel that carries blood from the heart to the body) or another blood vessel breaks, interrupting blood flow to an area of the brain. When either of these things happens, brain cells begin to die and brain damage occurs. When brain cells die during a stroke, abilities controlled by that area of the brain are lost. These abilities can include speech, movement, and memory. How a stroke patient is affected depends on where the stroke occurs in the brain and how much of the brain is damaged. For example, someone who has a small stroke may experience only minor problems, such as weakness of an arm or leg. People who have larger strokes may be paralyzed on one side or lose their ability to speak. Some people recover completely from strokes, but more than two-thirds of survivors will have some type of disability.